"The time is out of joint": Pain, paresthesias, and weakness in a preadolescent

Your patient is a 10-year-old Latino girl brought to the clinic by her very concerned mother. The complaint is leg and joint pain-severe enough to make walking difficult. The visit comes after your colleague at the clinic saw the girl about a month ago for an unusual rash described in the record as a brownish, linear, papular eruption, possibly urticaria pigmentosa. He prescribed hydroxyzine.

Three weeks later, you read, your colleague saw the girl again, this time for a complaint of pain in the left wrist, symptoms of a common cold, and a barky cough of approximately two weeks' duration. She complained that she was feeling generally tired. He prescribed azithromycin for suspected Mycoplasma infection. Examination of the hands and arms was unremarkable. He instructed the mother to watch for joint swelling.

QD: Pain and a long nap

The girl denies weight loss or diminished appetite. She does complain of generalized fatigue and increased sleepiness: She takes a three-hour nap every day after school! You begin by taking the history.

Your patient is in the fourth grade and, her mother reports, is a good student. She lives with her mother and a younger, school-age brother. Her parents have been separated for about nine months; the father is involved in his children's life on an almost daily basis, the mother reports. She denies a history of domestic violence in the family.

The medical history is noncontributory. The girl was delivered at term. She has no history of hospitalization, surgery, or serious illness; has been fully immunized; and does not have known drug allergies. Hydroxyzine and azithromycin are her only medications over the past several months. She has had no recent exposure to ticks, has not been camping, and has not traveled recently. She has had no recent illnesses other than "colds" and "coughs" and no gastrointestinal problems.

The family history is positive for osteoarthritis on the maternal side, and a maternal grandmother who has rheumatoid arthritis.

On physical examination, your general impression is of a well-nourished, well-developed, slightly obese girl who is not in acute distress. The earlier rash over the left forearm is barely noticeable.

Height is at the 50th percentile for age; weight, between the 75th and 90th percentiles. Vital signs are unremarkable: Blood pressure, 107/59 mm Hg; pulse, 69/min; temperature, 97.3°F; and respiratory rate, 22/min. The ear, nose, and throat exam is benign. Oral mucosa is moist and without lesions. There is no conjunctival injection. Bilateral red reflexes are clear. Heart sounds are normal; no heart murmur is heard. Breath sounds are clear. The abdomen is soft and nontender; bowel sounds are present; and you do not palpate any masses or hepatosplenomegaly.

The genitalia are normal and Tanner Stage I. You note no cervical, axillary, or inguinal lymphadenopathy. The neck is supple without thyromegaly.

The patient expresses pain in the metacarpophalangeal and interphalangeal joints of both hands and describes pain in almost all other joints-neck, spine, and large and small joints of the extremities, including shoulders, hips, elbows, and knees. On thorough examination of those joints, you cannot detect swelling, erythema, effusion, or increased warmth over the skin-the tenderness she expresses over the metacarpophalangeal and interphalangeal joints by palpation notwithstanding. The pain is elicited in all small finger joints by passive motion, by wrist movements, and by examination of the large joints of the lower extremities, including knees and hips. She appears to have hyperflexible finger joints. Gait is guarded but there is full range of motion in all joints.